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4. A 57-year-old CKD 5 called for cadaveric renal transplantation. He has been on the waiting list for 6 years. 212 mismatch, no DSA and negative FAXM. He was recently diagnosed with biopsy-proven BCC on the scalp waiting for excision (confirmed 2 days before this admission).
- How do you manage this case?
- Will you proceed with the transplantation as planned?
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How do you manage this case?
Management consists of a transplant dermatologist, a surgeon, and counselors.
Basal cell carcinoma is the second most prevalent form of skin cancer in transplant recipients with impaired immunity. In the general population, basal cell carcinoma is the most prevalent form of cancer. The likelihood of developing basal cell carcinoma is tenfold that of the general population.
It grows slowly and spreads infrequently to other parts of the body. It can cause extensive damage and destruction of the epidermis and underlying structures if left untreated.
Electrodesiccation and curettage, surgical excision, and Mohs surgery may all be used to treat basal cell carcinoma. Radiation may also be a treatment option.
Will you proceed with the transplantation as planned
Yes, after surgical excision and management of the BSC, I will undergo transplantation immediately.
There is no delay period
Posttransplantation care: education, consciousness, and observation
Pretransplant skin cancer alone is a risk factor for posttransplant skin cancer, and the patient must be informed and educated accordingly.
In the posttransplant period, annual self-examination and examination by a physician are required for skin cancer screening.
Patients should be instructed to avoid overexposure to the sun and use sunblock.
Any suspicious lesion should be biopsied. Immunosuppression:
Avoiding azathioprine and starting mTORi will be recommended
Transplant patients are more prone to a basal cell carcinoma (BCC) diagnosis because they require long-term use of immunosuppressant medications to prevent organ rejection. Those medications can impair the capacity of the immune system to repair or destroy UV rays, which are a major factor in the development of skin.
*Cancel tx and remove bcc
https://www.dermatologytimes.com/view/relationship-between-bcc-and-transplant-patients-analyzed-at-eadv-congress
How do you manage this case?
Management of the patient includes involvement of MDT (surgeon, dermatologist, renal transplant physician)BCC is likely and it is 10 more common compared to general population.
General /Supportive meaures: avoidance of sun exposure and use of sun screens. Self skin examination monthly and examination by dermatologist -6-12 mthly for early detection of skin cancer.
Specific treatment: Complete Surgical excision; Curretage and electrodesiccation; Radiation therapy,Photodynamic therapy, intra-lesional therapy (interferon, & imiquimod, retinoids, 5-fluouracil)
Reduction of immunosuppression-antimetabolite should be stopped and can be replaced with sirolimus
Will you proceed with the transplantation as planned?
BCC is not an aggressive tumor and rarely metastasize, and already the patient is on waiting list for long so better to proceed for transplant without waiting time but close follow up post-transplant needed for early recurrence and timely management.
REFERENCE:
1- Ponticelli C, Cucchiari D, Bencini P. Skin cancer in kidney transplant recipients. J Nephrol. 2014 Aug;27(4):385-94
57 y old, ESRD patient, 6 years on transplant waiting list, recently diagnosed with scalp BCC and is waiting for total excision received a cadaveric renal transplant offer 212 mismatch (high risk immunological offer), no DSA, negative cross-match.
How do you manage this case?
· BCC is slowly growing, locally invasive skin tumour, causing destructive effects on skin and surrounding tissues. However, it rarely metastasize.
· Treatment occurs in liaise with the dermatology and oncology teams as part of MDT.
· Choice of treatment depends on the tumour size, location, pathology, and patient preference.
· Options include local surgical excision, Mohs surgery, curettage and electrodessication. In mild cases cryosurgery, topical imiquimod or fluorouracil can be used.
Will you proceed with the transplantation as planned?
· Yes. I will go ahead as the patient has been on a wait-list for long time, low risk for metastasis and a deceased kidney has already been offered to the patient.
· Patient require proper counselling about the recurrence risk. Also, instructions about Sun protective methods and the need of frequent skin examination and to be vigilant to report for any new developing skin lesion.
· ATG Induction can be used because of high immunological risk offer. Consider switching from Tacrolimus to mTORi after wound healing in this scenario
References:
1. Berman H, Shimshak S, Reimer D, Brigham T, Hedges MS, Degesys C, Tolaymat L. Skin Cancer in Solid Organ Transplant Recipients: A Review for the Non dermatologist. Mayo Clin Proc. 2022 Dec; 97(12):2355-2368.
2. Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med. 2003 Apr 24; 348(17):1681-91.
A 57-year-old CKD 5 called for cadaveric renal transplantation. He has been on the waiting list for 6 years. 212 mismatch, no DSA and negative FAXM. He was recently diagnosed with biopsy-proven BCC on the scalp waiting for excision.
As BCC has a good prognosis and the lesion is locally malignant besides very low possibility of BCC metastasis in the other hand my patient has long period of waiting list
So I will proceed transplantation with excision the lesion simultaneously as immunosuppression may exacerbate the BCC in case latent excision.
How do you manage this case?
Surgical excision of this local basal carcinoma is needed.
Will you proceed with the transplantation as planned?
No waiting time needed for this local basal cell carcinoma.We should go with transplantation as planned with excision can be done simulaneously with transplant.
Q1: BCC is slow growing and usually without spread. Its treatment includes complete excisional surgery or Mohs surgery.
Q2: yes, excisional surgery at the same time as renal
transplantation could be done because there is no need for waiting time for
BCC. post-transplant the recipient should be informed about sun protection,
monthly self-examination, and eventually dermatologist examination- avoidance
of azathioprine and switching to mTORi is recommended.
Reference:
Knoll, G. A., & Chadban, S. J. (2018). Preexisting Cancer in Transplant Candidates: Time for a Change in Practice? In Transplantation (Vol. 102, Issue 7). https://doi.org/10.1097/TP.0000000000002177
I would proceed with extracting this BCC and performing staging tests to exclude metastasis. In this case, performing magnetic resonance imaging in the brain at least. If possible, perform a PET SCAN.
After excluding metastasis and assessing the need for some chemotherapy treatment, I would put the patient back on the kidney transplant waiting list.
Yes, after removing greater commitment would re-establish the patient on the transplant queue.
· If the patient is sitting in front of me with a kidney in a box?
In this case, where a negative would mean the loss of the organ, I would explain to the patient about the increased risk of morbidity and mortality, but I would propose that we perform the transplant and excision of the lesion with subsequent staging and follow-up.
REFERENCE:
– Ponticelli C, Cucchiari D, Bencini P. Skin cancer in kidney transplant recipients. J Nephrol. 2014 Aug;27(4):385-94. doi: 10.1007/s40620-014-0098-4. Epub 2014 May 9. PMID: 24809813.
– Amos-Arowoshegbe EO, Varghese R, Joseph AB, Kanu-Ivi C, Sadi N, Sadana S, Latif F, Abdul A, Ratra R, Blume K, Tiesenga F. Basal Cell Cancer of the Scalp. Cureus. 2022 Jun 30;14(6):e26469. doi: 10.7759/cureus.26469. PMID: 35919367; PMCID: PMC9338841.
D; is the correct answer bcz the patient has long waiting time and best matched graft and the BCC is very superficial and one can excise it very easily with minimal time and we can also do active surveillance after the excision for any recurrence.
D; is the correct answer bcz BCC is very superficially and u can resect it easily with no time and no complication. u can do later on active surveillance also after excision therefore it is not a big issue to excise simultaneously with transplantation
– Proceed for transplantation
– Later surgical excision & topical 5FU for BCC
– Reduction of immunosuppression and switch from CNI to mTORi as soon as possible.
– Counseling patient regarding sun protection and self examination.
Yes i will proceed for transplantation as BCC is usually locally malignant tumour.
BCC is locally malignant tumor with low risk of metastasis so no need to cancel the operation I will go directly for operation with simultaneous excision during transplant or after operation.
Immunosuppression regimen
Non depleting induction (Basiliximab) is preferable followed by triple immunosuppression (Tacrolimus, MMF, steroids).
Switching of tacrolimus to sirolimus after (after wound healing), or by 6-12 months post-transplant depending on graft function (risk of rejection).
Patient should be educated regarding self-examination monthly by himself then every 6-123months by dermatologist, avoid sun exposure and use of sun protectives measures.
Reference
1. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
2. Clark C. Otleya, Ryutaro Hiroseb, Stuart J. Salaschec. Skin Cancer as a Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5: 2079–2084
Discussion
I would go ahead the transplant and excision of BCC simultaneously (option D) with rotation flap closure by help of a plastic surgeon.
The skin lesion (BCC) on the scalp is small (2-3cm) – seems low-risk (easily treatable)
Surgical excision (with 3-4mm margin) is very effective – curative with less recurrence risk (<2-8%) by b5 year. 1
Excision of the scalp lesion with rotation flap closure – is not so difficult operation, can be done under same anaesthesia and post-op convalescence shall be same as transplant. Doing it later on may delay use of mTORi which causes delayed wound healing.
Various guidelines do advocate 0-waiting time in cases of localized non-melanoma skin cancers due to its high cure rate, low recurrence risk, and accelerated risk of death on dialysis, which can be minimized after transplant, with added survival benefit and good quality life gain. (2)
Patient has to be advised for stringent follow-up – educated for Self-examination, Dermatologist consultation every 6-12 months and report to transplant team in case of any suspicious lesion.
References:
1. Peris K, Fargnoli MC, Garbe C, Kaufmann R, Bastholt L, Seguin NB, et al. Diagnosis and treatment of basal cell carcinoma: European consensus-based interdisciplinary guidelines. Eur J Cancer. 2019; 118:10-34.
2. Lim WH, Au E, Krishnan A, Wong G. Assessment of kidney transplant suitability for patients with prior cancers: is it time for a rethink? Transpl Int. 2019;32(12):1223-40.
3. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation.
4. Knoll G, Cockfield S, Hansen TB, et al. (for The Kidney Transplant Working Group of the Canadian Society of Transplantation). Canadian Society of Transplantation: consensus guidelines on eligibility for kidney transplantation. CMAJ 2005 November 08; 173 (10): S1-S25. DOI: https://doi.org/10.1503/cmaj.1041588.
BCC is a local malignant tumor.
Risk of metastasis is very rare.
No absolute contraindication for renal transplantation, but if metastasis happen which is rare, we should wait for 5 years .
As the patient waiting for a long time for transplantation, it’s logic to go ahead for transplantation with simultaneous removal of the lesion with marginal excision.
We should counsel the patient regarding the risk of recurrence after kidney transplantation, and the importance of post transplant precautions like avoiding sun exposure and the use of sunblock with regular self examination monthly and every 6 months by dermatologist.
Reference:
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
The given patient is a deceased donor candidate recipient who is admitted for renal transplant from a cadeveric donor…. The offer kidney is 212 mismatch kidney with no DSA and a negative flow cross match…. The patient has already been on the waiting list for 6 years…. This patient was diagnosed as BCC of scalp (biopsy proven) 2 days back…..
The patient needs management of BCC which is easy as compared to SCC as it is a highly localized lesion and will not metastasize as compared to other skin malignancies… Patient needs a wide local excision of the BCC…. Mohs micrographic surgery and systemic therapy with sonidegib, topical imiquimod are the other options for treatment for BCC….
AS the tissue diagnosis of BCC is confirmed there is no need for further investigations to rule out spread of the malignancy…. Patient needs to be informed about the monitoring of the skin for new lesions after transplant..He needs to be counselled about skin exposure to sun and usage of SPF >50 from UVB and 5 star rating for UVA….avoid sun exposure in the noon time is advised and to wear fully covered clothes if sun exposure is unavoidable… Patient should be counselled to report immediately if there is a new skin lesion post transplant….
Patient should be converted to mTOR inhibitors after the wound healing happens and ASAP as it will have an anti proliferative effect
I will proceed with transplant as planned as the patient has been on the wait list for a long time…. BCC has no waiting time before transplant and can be done immediately…Intraoperative excision of the BCC will not prolong the ischemia time and can be done….the option of doing the excision of BCC at a later date ,may not be a good idea as the malignancy is exposed to the immunosuppresive drugs
As this patient has localized, small size BCC in the scalp so the patient can undergo renal transplantation with excision of BCC simultaneously during transplant surgery. The risk of metastasis for BCC is estimated to be between 0.05 to 0.1 percent.
Patient should be educated regarding self-examination to prevent recurrence, dermatology follow up. Ideally AZA should be avoided in the immunosuppression regime.
A. Cancel the transplant and remove the patient from the waiting list.
Ans; false; we can proceed this is a localize disease, can be removed post-transplantation.
B. Proceed with the transplant and excise the BCC later, as it is locally malignant.
Ans; correct. Can proceed, its recommended if a lesion to be treated and wait for 2 years then proceed, currently in a position cannot wait otherwise will lose the chance.
C. Cancel the transplant and ask the surgeon to remove the BCC first
Ans; False. Because there is no any emergency to removal now, rather to proceed to transplant, metastasis very rare.
D. Go ahead with the transplant and excision of the BCC simultaneously.
Ans; false. Can be removed safely after transplantation.
E. None of the above.
Ans; false.
· This lesion looks superficial. Curettage can be done and re-evaluate.
· No waiting time is needed for curatively treated non-metastatic basal cell and squamous cell carcinoma of the skin.
· BCCs have a much more limited biologic potential for metastasis and death, with treatment emphasis instead focused on limiting morbidity from disease.
· The most common treatment approaches are superficial destructive modalities and surgical techniques including curettage, cryosurgery, wide local excision, and Mohs micrographic surgery.
Posttransplant Screening and Protection
· Sun protection with high sun protection factor (SPF) sunscreen
· Use of physical UV light barriers, such as photoprotective clothing, hats, sunglasses
· Avoidance of exposure to UV light by limiting outdoor activity during peak daylight (10 AM to 4 PM)
· Abstinence from tanning or artificial UV sources d Education on the ABCDE rule for skin cancer identification: asymmetry, border, color, diameter, elevation/evolving
· Monthly self-examination of skin and annual skin examination by a dermatologist or primary care physician experienced with skin cancer
Modification of Immunosuppression
· Several studies have suggested that conversion from calcineurin inhibitors to mTOR inhibitors, including sirolimus and everolimus, reduces the incidence of posttransplant NMSC
· There are some data that transitioning to MMF monotherapy decreases the risk of post-transplant NMSC
1)KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation
2) Skin Cancer in Solid Organ Transplant Recipients: A Review for the Non-dermatologist.
I think D would be the most appropriate choice if we consider the long waiting period, the nature of malignancy, removing cancer before starting the long immunosuppression journey and the availability of a qualified surgical team.
Management:
The prospective deceased donor kidney transplant recipient, with recently detected biopsy-proven Basal cell carcinoma of scalp, being offered a 212 mismatch kidney with no DSA and negative cross-match.
Basal Cell Carcinoma in head neck region is always at high risk of recurrence, though the size of the lesion is small. In this type of cases Mohs micrographic surgery (MMS) is suggested.
Proceed to planned transplantation:
Yes, I want to proceed to this transplantation with simultaneous surgery of this BCC and renal transplantation. Here, multidisciplinary approach is needed including plastic surgeon, transplant surgeon, nephrologist, dermatologist and oncologist. Appropriate counseling is paramount here along with close post-transplant follow-up with emphasis on sun-protective behavior.
An mTOR inhibitor based immunosuppressive regimen would be preferable in this scenario.
References:
(i) UpToDate
(ii) Berman H, Shimshak S, Reimer D, Brigham T, Hedges MS, Degesys C, Tolaymat L. Skin Cancer in Solid Organ Transplant Recipients: A Review for the Nondermatologist. Mayo Clin Proc. 2022 Dec;97(12):2355-2368. doi: 10.1016/j.mayocp.2022.07.004. Epub 2022 Nov 3. PMID: 36334939.
BCC is a local malignant tumor.
Risk of metastasis is very rare.
No absolute contraindication for renal transplantation, but if metastasis happen which is rare, we should wait for 5 years .
As the patient waiting for a long time for transplantation, it’s logic to go ahead for transplantation with simultaneous removal of the lesion with marginal excision.
We should counsel the patient regarding the risk of recurrence after kidney transplantation, and the importance of post transplant precautions like avoiding sun exposure and the use of sunblock with regular self examination monthly and every 6 months by dermatologist.
Reference:
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
I will accept the kidney after counselling with patient
BCC is not a systemic cancer
will involve surgical oncology for tumor excision at the same time of recipient surgery as BOTH can be done at the same time
recipient will be at HIGH RISK of local recurrence with addition of IS
Surgical removal and free marginal excision and proceed to transplant as planned.
The prognosis is almost always favorable for BCC.
Basal cell Carcinoma
Risk of recurrence and death from pre-transplantation
basal cell carcinoma.
The risk of death from BCC is vanishingly small. There-
fore, in almost all cases, a history of BCC would not be
a contraindication to transplantation when considering sur-
vival. Although rare, metastatic BCC is very difficult to treat and thus it would represent an absolute contraindication to transplantation unless a disease-free interval of at least least 5 years had passed since the last manifestations.
pre-transplantation BCC or SCC is a marker for an increased likelihood of multiple de novo NMSCs after transplantation. Even among nonimmunosuppressed patients, in 44% of patients with prior BCC, another BCC develops within 3 years and in 6% an SCC develops within
3 years .
a history of NMSCs should be viewed as an opportunity to implement aggressive preventive treatments, including sun protection, under the close surveillance an experienced dermatologist before the
patient is considered for organ transplantation.
Sun protection behaviour, defined as hours spent outdoors per week, use of sunscreen, wearing protective clothing and seeking shade.
Patients who received behavioural interventions reported improved sun protection behaviour scores.
Using mTORis as immunosuppressive therapy ,photodynamic therapy and immune response modifiers.
Using 5% imiquimod cream that found a reduction in the incidence of skin dysplasia skin atypia and viral warts
Reference
Minireview
Skin Cancer as a Contraindication to Organ Transplantation
Clark C. Otley
Ryutaro Hirose
and Stuart J. Salasche
Division of Dermatologic Surgery, Mayo Clinic,
Rochester, Minnesota, USA
Department of Surgery, Division of Transplantation,
University of California, San Francisco, California, USA
Division of Dermatology, University of Arizona Cancer
Center, Tucson, Arizona, USA
Corresponding author: Clark C. Otley, M.D.,
Otley.clark@mayo.edu
OUR CASE;
MGT;
Will you proceed with the transplant?
REF;
BCC is locally malignant tumor with low risk of metastasis so no need to cancel the operation I will go directly for operation with simultaneous excision during transplant or after operation.
Regarding immunosuppression
I would prefer to give him non depleting induction with basiliximab followed by triple immunosuppression including tacrolimus, MMF and steroids.
I would consider shifting from tacrolimus to sirolimus after 1year post-transplant (wound healing and risk of rejection).
Patient should be educated regarding self-examination monthly by himself then every 6m by dermatologist , avoid sun exposure and use of sunblock.
Reference
1. Clark C. Otleya, Ryutaro Hiroseb, Stuart J. Salaschec. Skin Cancer as a Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5: 2079–2084
2. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
treatment for a BCC depends on its type, size and location, the number to be treated,
patient factors, and the preference or expertise of the doctor.
Most BCCs are treated surgically.
Long-term follow-up is recommended to check for new lesions and recurrence; the latter
may be unnecessary if histology has reported wide clear margins.
Mohs micrographically controlled surgery.
Mohs micrographically controlled excision:
involves examining carefully marked excised tissue under the microscope, layer by layer,
to ensure complete excision.
Advantage over cryotherapy and photodynamic therapy:
YES.
The risk of death from BCC is small.
Therefore, in almost all cases, a history of BCC would not be a contraindication to
transplantation when considering survival.
References:
1-
Clark C. Otleya,Ryutaro Hiroseb and Stuart J. Salasche.Skin Cancer as a
Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5:
2079–2084.
Since patients with a history of pretransplant skin cancer have a nearly threefold increased risk of post-transplant malignancies, including cSCC, BCC, lymphoproliferative disorders, and solid tumors, compared with patients without pretransplant skin cancer , this is a tough decision as to proceed with even without treatment of BCC.
Patient should be explained in detail the possible consequences and then a collective decision should be taken. I would prefer to proceed and will deal with BCC as soon as possible after transplant.
Would prefer to keep him on Sirolimus from day one
Data from two observational studies suggest that immunosuppression with mycophenolate mofetil may be associated with lower risk for skin malignancy compared with azathioprine-based regimens
Management
Recipient with basal cell carcinoma awaiting transplantation management requires multi-disciplinary approach with oncologist, transplant physician and dermatologist.
A through physical examination for any other lesion and lymphadenopathy is required.
If the lesion is localised no other imaging is required.
Treatment modality is surgery, techniques used include:
Other treatment modalities if surgery is not feasible:
After excision the patient should be advised on sun protective habits- avoidance of midday sun, use of sun screen and protective clothing.
Will you proceed with the transplant as planned?
Yes, BCC rarely metastasises hence no need to cancel the transplant.
Lesion can be excised concurrently during transplantation.
Induction should be done with basiliximab and maintenance therapy with CNI based regimen.
The CNI should then switched to MTOR inhibitors due to its anti carcinogenic effect after 3 months.
Regular skin examination with good lighting should be done.
References
Preexisting Cancer in Transplant Candidates Time for a Change in Practice?
Greg A. Knoll, MD, MSc, FRCPC and Steven J. Chadban, BMed, PhD, FRACP
Skin Cancers in Organ Transplant Recipients. A Mittal, O R Colegio
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
I am enjoying participation in this debate.
Excision of this lesion would not hardly prolong the procedure.
Even if this can not be closed primarily, just in case, this can be grafted once we have histopathology report. Taking the help of a plastic surgeon to excise while transplant team is busy writingt he operation note is sensible. It will be be possible to achieve primary closure of a small lesion like this.
How do you manage this case?
This is basal cell carcinoma ,the history of BCC is not contraindicated to transplantation unless metastatic which is rare .
Basal cell carcinomas developed an average of 6.9 years after transplantation, sooner after heart than kidney transplantation, and showed a relative predilection for heart allograft recipients.
basal cell carcinomas were predominantly found on the head and neck, but extracephalic locations were significantly more frequent in transplant recipients .
organ transplant recipients (OTRs) are at increased risk for developing various cancers,including skin cancers. Premalignant and malignant cutaneous tumors, including basal cell carcinomas (BCCs) ,account for the most common malignancies developing in OTRs as a result of chronic immunosuppression, light exposure, and possibly also human papillomavirus infection.
Will you proceed with the transplantation as planned?
I will proceed towards the transplant this patient who was waiting for 6years first council the patient and well educate him about this then after surgical excision and treatment pretransplantion with follow up postransplation:-
Topical 5 FU
Reduction of immunosuppression
Consider Sirolimus
References
1.Naldi LFortina ABLovati S et al. Risk of nonmelanoma skin cancer in Italian organ transplant recipients: a registry-based study. Transplantation. 2000;701479- 1484
2.Gupta ACardella CHabermann H Cutaneous malignant neoplasms in patients with renal transplants. Arch Dermatol
Clinical guedlines for kidney transplant 2021
Basal cell carcinoma ( BCC ).
Common type in the frequency of NMSCs in the general population, rarely fetal while after SOT the frequency is reversed with more prevalence of SCC.
Non-melanoma skin cancers (NMSCs) are mostly basal cell carcinoma (BCC), in Caucasians,
Most NMSCs are easily treatable. Death is rare; when it occurs, it does so from metastatic cSCC, or from local invasion by ignored BCC or cSCC.
More common in men, older age, fair skin, and > 80% of NMSC involve the head and neck, due to prolonged sun exposure like the indexed case, immunosuppression exposure like SOT candidates including kidney transplant candidates with CNI exposure can upregulate TGF‐β1 and VEGF (2,3). Both of which are known to contribute to cancer growth and angiogenesis. they also suppress anti‐oncogenic genes (p53 via NFAT‐ATF3) and their dose depended on the effect (cumulative dose of immunosuppression over time of the exposure) (2).
According to the morphological feature of the BCC can identify the risk
Low-Risk BCC, usually superficial, nodular lesion < 2 cm
High-risk BCC, Morphoeic, micronodular infiltrative, Basosquamous BCCs on the head (face and scalp)
High-risk features of BCC for recurrence:
Lesion size > 2cm
Sun exposure site central face, scalp
Poorly defined clinical margins
High-risk histological sub-type
Histological features of aggression; peri-neural or peri-vascular involvement
Failure of previous treatment (the tumor is a recurrence)
Immunosuppression
The indexed case of a male candidate for kidney transplantation has been on a long dialysis waiting list and was recently diagnosed with BCC based on excisional biopsy results involving sun exposure site, fair skin, and offered DD with standard immunological risk no DSA, and negative FXM, the lesion looks superficial with a clear margin and central ulceration
we need the MDT approach and communicate to the dermatologist or oncologist and discussed the histology report of his biopsy if the histology confirms its non-infiltrative basal cell carcinoma (BCC) <2 cm in size should be excised with a margin of 4–5 mm. smaller margins (2–3 mm) may be taken in sites where reconstructive options are limited
This patient should receive education in self-examination and skin cancer prevention measures. Including avoiding UV radiation, sun exposure, and use of sunblock
Those with recurrent or multiple BCCs should be offered an annual review.
Modification of immunosuppression after 3 months, by CNI minimization with the addition of m TOR inhibitors like sirolimus or everolimus with a target trough level around 5.5 with the range (3-8ng) as tolerated and balanced with the risk of rejection, this approach was found to reduce the incidence of NMSC, in particular, BCC but not SCC after SOT based on the available evidence from one registry data (4).
So will go with option D if its low grade BCC
References
1. Newlands C, Currie R, Memon A, Whitaker S, Woolford T. Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016 May;130(S2):S125-S132. doi: 10.1017/S0022215116000554. PMID: 27841126; PMCID: PMC4873942.
2. Eberhardt W, Nasrullah U, Pfeilschifter J. Activation of renal profibrotic TGF-beta controlled signaling cascades by calcineurin and mTOR inhibitors. Cell Signal 2018; 52: 1
3.Basu A, Contreras AG, Datta D, et al. Overexpression of vascular endothelial growth factor and the development of post‐transplantation cancer. Cancer Res 2008; 68: 5689.
4. Opelz G, Unterrainer C, Susal C, Dohler B. Immunosuppression with mammalian target of rapamycin inhibitor and incidence of post‐transplant cancer in kidney transplant recipients. Nephrol Dial Transplant 2016; 31: 1360.
Well done, thank you.
4. A 57-year-old CKD 5 called for cadaveric renal transplantation. He has been on the waiting list for 6 years. 212 mismatch, no DSA and negative FAXM. He was recently diagnosed with biopsy-proven BCC on the scalp waiting for excision (confirmed 2 days before this admission).
Issues/ concerns
– 57yo, CKD5, on the waiting list for 6years, admitted for cadaveric kidney transplantation
– 212 mismatch, no DSA, negative FAXM
– recently diagnosed biopsy-proven scalp BCC (diagnosis confirmed 2 days before this admission)
– awaiting excision of the lesion
Introduction (1)
– skin malignancies are the most common worldwide
– risk of metastasis or recurrence varies considerably but for most transplant candidates the risk is minimal and transplant remains appropriate
– patients with active metastatic cancer should not be considered for transplantation
– patients with silent, residual skin cancer cells or micrometastases are at increased risk of cell proliferation with immunosuppression
– there is also a risk for de novo primary skin malignancies developing at other sites
How do you manage this case? (1, 2)
– multidisciplinary approach involving the dermatologist and the oncologist
– the patient requires optimal evaluation to estimate the risk of recurrence, metastasis or development of new primary cancer
– transplant dermatologist should assess the clinical, surgical and pathological details of the skin cancer
– PET scan may be useful to screen for any foci of metastatic melanoma, high-risk SCC or merkel cell carcinoma
– for detection of BCC and other slow-growing tumors CT scan can be used
– estimating the prognosis requires putting into consideration how recently the primary tumor occurred
– if this is primary BCC, the standard of care is surgical excision and this can be done after transplantation
– Sun protection (sun avoidance, sun-protective clothing, use of sunscreen) and practicing skin self-examination – sun protection decreases incidence of skin malignancies (3)
– Post-transplant surveillance appointments with a dermatologist – to monitor for development of new lesions, locally recurrent lesions and metastatic disease
– modulation of immunosuppression: –
Will you proceed with the transplantation as planned? (1, 2)
– yes, I would proceed with transplant
– BCC is usually a locally destructive tumor hence the prognosis is almost always favourable for BCC compared with SCC
– in very rare circumstances BCC may be locally advanced or metastasize
– BCC is not a contraindication to transplantation unless it is metastatic BCC
– metastatic BCC is rare, difficult to treat hence requires a 5year disease-free interval before transplantation can be considered
References
1. Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2005 Sep;5(9):2079-84. PubMed PMID: 16095486. Epub 2005/08/13. eng.
2. Mittal A, Colegio OR. Skin Cancers in Organ Transplant Recipients. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2017 Oct;17(10):2509-30. PubMed PMID: 28556451. Epub 2017/05/31. eng.
3. Bangash HK, Colegio OR. Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients. Current treatment options in oncology. 2012 Sep;13(3):354-76. PubMed PMID: 22592596. Epub 2012/05/18. eng.
· How do you manage this case?
The index patient is a prospective deceased donor kidney transplant recipient, with recently detected biopsy-proven Basal cell carcinoma of scalp, being offered a 212 mismatch kidney with no DSA and negative crossmatch.
The diagnosis was done 2 days back, the patient will require treatment of Basal Cell Carcinoma (curettage, cryosurgery, wide local excision, Mohs micrographic surgery and systemic therapy like vismodegib and sonidegib) (1).
In the current scenario, it would have been ideal to get the wide excision of the lesion done at the time of biopsy itself, implying the lesion in totality has been removed while taking the biopsy.
· Will you proceed with the transplantation as planned?
Yes. The transplantation should go ahead as the patient has been on a wait-list for long time, and a deceased kidney has already been offered to the patient. Assuming that the lesion has been excised in totality, there is no wait-time (and hence no contra-indication) for transplant in non-metastatic basal cell carcinoma (2).
Even if the lesion has not been excised in totality, the transplant can proceed with either a simultaneous resection of the lesion and kidney transplant (preferred), or a kidney transplant followed by resection of the lesion at a later stage.
The patient would require counselling and close post-transplant follow-up with emphasis on sun-protective behaviour.
An mTOR inhibitor based immunosuppressive regimen would be preferable in this scenario.
References:
Well done, thank you.
How do you manage this case? Will you proceed with the transplantation as planned?
57 y old, ESRD patient, 6 years on transplant waiting list, recently diagnosed with scalp BCC and is waiting for total excision received a cadaveric renal transplant offer 212 mismatch (high risk immunological offer), no DSA, negative cross-match.
Excised BCC with no metastasis doesn’t necessitate waiting time before SOT.
BCC is slowly growing and usually localized and it rarely metastasizes.
Treatment options of BCC include: surgical excision, curettage, electrodesiccation
Yes, I will proceed.
I will consent the patient for the surgeon to excise the lesion intra-operatively.
Ask the surgeon to excise the lesion intra-operatively.
Dermatology consultation to give advice about other topical agents (like imiquimod, Fluoro-uracil, photodynamic therapy or photosensitizers)that can be used for treating BCC.
Immunosuppression:
Induction: ATG because of high risk immunological offer.
Maintenance: avoid Azathioprine, consider m-TOR inhibitors, or reduced doses of CNI with lower target therapeutic levels.
Education about recurrence of skin cancer: regular self-examination, annual dermatology follow-up, sun-protection measures
Reference:
Uptodate
Handbook of transplantation.
Well done, thank you.
How do you manage this case?
-BCC is the most common skin cancer among SOT recipients.
-Lesions are slow growing, and metastatic disease is a very rare event.
-It can be locally invasive, aggressive, and destructive effects of this tumor on skin and surrounding tissues
-If left untreated, these cancers may result in significant morbidity.
-Recurrence rate is very low.
-No wait time period is required for transplant candidate.
Management of BCC:
-Depend on tumor size, location, and pathology, and patient preference.
– Dermatology and oncology team opinion is essential.
*Surgical excision with 4 mm free margin:
– Recommended as first-line therapy
– for nodular or superficial BCC <20 mm in diameter located on the trunk and extremities
* Mohs surgery
– 100% margin control.
-Offers highest cure rate for both primary and recurrent BCCs
– Maximizing preservation of normal tissue.
* Curettage and electrodesiccation:
– It does not allow histologic confirmation of tumor removal
– It is not recommended for BCCs located on terminal hair-bearing skin, due to the risk of follicular extension of the tumor
-May cause a more visible scar
*Other options for low risk BCC includes;
– Topical imiquimod or topical fluorouracil
-Photodynamic therapy (PDT) and cryosurgery.
– Consider switching from Tacrolimus to mTORi after wound healing.
– Frequent skin examination and surveillance for development of any skin lesion.
– Sun protective methods. Avoid mid-day sun exposure, avoid bed tanning, apply broad spectrum sunscreen, Patients should cover up with long sleeved shirts and pants, wear a hat and sunglasses when outdoors.
Will you proceed with the transplantation as planned?
I prefer to go for surgical excision with clear margin with closure of surgical defect.
Option D: Simultaneous transplantation and surgical BCC excision seem reasonable for the following:
-Candidate is old age patient with long waiting time on transplant list.
-Tumor has low risk for metastasis.
– Prognosis generally good.
– Reduce cold ischemia time.
References:
Ponticelli, C., Cucchiari, D. & Bencini, P. Skin cancer in kidney transplant recipients. J Nephrol 27, 385–394 (2014).
Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med. 2003 Apr 24;348(17):1681-91. doi: 10.1056/NEJMra022137. PMID: 12711744.
Thank you. See my comment above.
Ideally, we need to treat all skin cancer before RTX, but in this case, i will proceed with kidney transplantation and later on treat the BCC as it is a very benign tumor.
BCC is a slowly growing tumor which can be excised after transplantation and then close observation after that, as he was a donor on waiting list for 6 months
Thank you. See my comment above.
How do you manage this case?
BCC requires surgical excision with 4 mm margins. In low risk patients other options like electrodesiccation and curettage (EDC), cryosurgery, and Mohs micrographic surgery or topical therapy.
A multimodality approach involving dermatologist, oncologist and plastic surgeon is mandatory.
Patient education on using sunblocks and avoiding sun exposure
Will you proceed with the transplantation as planned?
Yes I would proceed with transplantation but will counsel the patient in detail. Patient will require excision post transplant. I will counsel him about risk of recurrence and preventive measures
Thank you. See my comment above.
This is a complex case. This patient has been on the waiting list for six years and has found a kidney with a 5/6 mismatch and no DSAs
He also has basal cell carcinoma
Since this is BCC and there is no waiting time after excision, I would go ahead with the transplant and simultaneously excise the lesion
Once the wounds have healed, he can be switched to mTOR inhibitors
How do you manage this case?
1. Team work-up; including plastic surgeon, dermatologist and oncologist.
2. Skin biopsy, staging and ruling out metastasis.
3. Surgical excision with safety margin. Mohs surgery has high cure rates for many forms of skin cancer. For basal cell carcinoma, the cure rate is around 99%. Mohs micrographic surgery (MMS) provides the best long-term cure rate of any treatment modality for BCC. MMS is the gold standard for treating high-risk BCCs and recurrent BCCs because of its high cure rate and tissue-sparing benefit. The high cure rate is attributed to an examination of 100% of all the tissue margins(1).
4. I will consider mTORi(sirolimus) instead of CNI plus MMF(2).
5. Topical 5-flourouracil can be used for refractory lesions.
6. Advice regarding post-transplant behavioral intervention to minimize the risk of recurrence:
a) Protective sunscreen and clothes.
b) Avoiding direct sunlight at the peak hours.
c) Doing routine self-examination of the skin for early detection of skin lesions or recurrence.
Will you proceed with the transplantation as planned?
I will proceed with the transplant as planned. BCC is a localized malignancy with 100% rate of cure and no delay necessary(3).
References
1. Al-Adra D, Al-Qaoud T, Fowler K, Wong G. De Novo Malignancies after Kidney Transplantation. Clin J Am Soc Nephrol. 2022 Mar;17(3):434-443. doi: 10.2215/CJN.14570920. Epub 2021 Mar 29. PMID: 33782034; PMCID: PMC8975024.
2. NIH; National Library of Medicine; Basal Cell Carcinoma Brianna McDaniel; Talel Badri; Robert B. Steele. Last Update: September 19, 2022.
3. Zwald F, Leitenberger J, Zeitouni N, Soon S, Brewer J, Arron S, Bordeaux J, Chung C, Abdelmalek M, Billingsley E, Vidimos A, Stasko T. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016 Feb;16(2):407-13. doi: 10.1111/ajt.13593. Epub 2016 Jan 28. PMID: 26820755.
Thank you. See my comment above.
How do you manage this case?
Will you proceed with the transplantation as planned?
BCC is locally invasive and doesn’t usually spread. So, excision with free margin usually is curative. Involvement of oncologist and oncology surgeon to decide management is essential. Since this patient has an offer, for which he is waiting for many years, we need to accelerate his management if possible before or immediately after surgery.
He is waiting for many years for this suitable offer. So, I will proceed since BCC is curative and doesn’t require a waiting period. However, follow-up plan with oncology, avoidance of sun exposure, and frequent visit to the clinic with skin examination is required.
Immunosuppressive medications with avoidance of CNI and azathioprine, instead we can use mTOR and MMF.
References:
1-Impact of Pre-Transplant Malignancy on Outcomes after Kidney Transplantation: United Network for Organ Sharing Database Analysis J Am Coll Surg. 2019 December ; 229(6): 568–579..
2-Hand book of kidney transplantation, 6th edition
How do you manage this case?
The most likely type of skin lesion on this patient’s scalp is basal cell carcinoma, which has a good prognosis, moderate growth, and a rare tendency to spread to other regions of the body.
Skin individuals undergoing organ transplants need to be regularly monitored for the emergence of new lesions, locally recurring lesions, and metastatic disease.
A dermatology consultation is required to confirm the diagnosis. In order to validate the depth and stage of the lesion, an excisional biopsy is required.
The following are some treatment options for managing BCC.
In small superficial lesions, local therapy using chemotherapeutic and immune-modulating drugs may be employed.
For superficial lesions, topical solutions containing 5% imiquimod or 5% fluorouracil might be used.
Photodynamic therapy (or laser therapy) is used to treat and prevent BCC.
Surgery is the primary form of treatment, and the strategy varies depending on the size, depth, and location of the tumor.
Will you proceed with the transplantation as planned?
As the donor kidney is cadaveric and has a high HLA mismatch of 212, the donor will likely receive aggressive induction (rATG or Almtuzumab) and maintenance therapy (CNI-based). The risk of skin cancer is higher with more potent immunosuppression. mTOR is not the best maintenance because it has the risk of rejection. So the lesion should be managed before the introduction of immunosuppression. Although this lesion is typically not lethal, rarely metastasizes, and there is a donor kidney available with a long recipient waiting list, we can move forward with transplantation right away with simultaneous excisional biopsy of the scalp lesion.
The patient must get counseling regarding the possibility of skin cancer recurrence following a transplant as well as preventative measures.
Programs to change behavior that emphasize the advantages of UV protection and regular self-skin checks
Frequent screening and follow-up are essential due to the high probability of recurrence and the possibility of developing NMSC or melanoma.
The patient should be instructed to perform monthly self-skin examinations and complete skin exams by dermatologists every 6–12 months.
Option D
The lesion has low risk being less than 2-3 cm(small) and localized in the scalp.
Surgical excision can be done with safety margin of 3-4 mm and recurrence is less than 2-8% 5 years following surgery.
Localized non-melanoma cancers have good cure rates and low recurrence risk. So ,no need for waitlist in addition to consideration of advantage of transplantation compared with dialysis.
After transplantation, regular self-examination and visits to dermatologist 6-12 monthly.
After wound healing , we may switch to mTOR inhibitors to gain anti-tumour effect.
-Lim WH, Au E, Krishnan A, Wong G. Assessment of kidney transplant suitability for patients with prior cancers: is it time for a rethink? Transpl Int. 2019;32(12):1223-40.
Thank you. See my comment above.
Basal cell carcinoma is the most common skin malignancy, etiology of BCC, depends on extent of sun exposure, inactivating mutations of PTCH1 or activating mutations of SMOm, females, and older age (>50 year old) population.
The histologic subtypes are:
Low risk =
(1) Superficial BCC, Lesions are pink, scaly, thin plaques that can mimic eczema or psoriasis.
(2) Nodular BCC, the most common variant, a well-defined, pearly, translucent papules or nodules with rolled borders and telangiectasias.
(3) Pigmented BCC is a subtype of nodular BCC that is more common in individuals with Fitzpatrick skin types III to VI.
High risk =
(1) Morpheaform (sclerosing) BCCs have higher rates of recurrence and perineural invasion. Tumors present as a depressed, waxy, scarlike plaques, often accompanied by ulceration.
(2) Infiltrative BCC is associated with higher rates of perineural invasion and recurrence.
(3) Micronodular BCCs are composed of dispersed micronodules whereas nodular BCCs are composed of aggregated nodules.
(4) Basosquamous carcinoma behaves more similarly to squamous cell carcinoma (SCC). Basosquamous carcinoma histologically consists of BCC and SCC in different areas with a transition zone of mixed differentiation, distinguishing this tumor from collision tumors.
The NCCN recommends skin examinations at least every 6 months to 12 months for the first 2 years after BCC diagnosis and then reduced to annually if appropriate. 24 Patients also should be educated about UV protection.
BCC is a slowly growing tumor that can generally be cured easily with surgical excision with 4 mm safety margins, with recurrence rate not exceeding 8%.
BCC showed the longest follow-up period (IQR, median, 10.7 [7.7, 14.0] years) and lowest death rate (25.3%), even lower than those of cancer-free patients.
How do you manage this case?
I would do excisional surgery with safety margins of 4mm, after a thorough examination of the scalp and adjacent lymph nodes, and proceed for a transplantation, with frequent self-monitoring and dermatologist clinic follow up.
I would consider induction with basilixumab, and maintenance immunosuppression with CNI, steroid, m-TOR, and MMF, in order to reduce drug toxicity and deleterious effect on the skin.
Will you proceed with the transplantation as planned?
Yes, I will proceed in transplantation with surgical excision of the lesion at the same time with a kidney transplantation.
References:
(1) Zwald F, Leitenberger J, Zeitouni N, Soon S, Brewer J, Arron S, Bordeaux J, Chung C, Abdelmalek M, Billingsley E, Vidimos A, Stasko T. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016 Feb;16(2):407-13. doi: 10.1111/ajt.13593. Epub 2016 Jan 28. PMID: 26820755.
(2) Basset-Seguin N, Herms F. Update in the Management of Basal Cell Carcinoma. Acta Derm Venereol. 2020 Jun 3;100(11):adv00140. doi: 10.2340/00015555-3495. PMID: 32346750; PMCID: PMC9189749.
(3) Kim DP, Kus KJB, Ruiz E. Basal Cell Carcinoma Review. Hematol Oncol Clin North Am. 2019 Feb;33(1):13-24. doi: 10.1016/j.hoc.2018.09.004. PMID: 30497670.
Thank you. See my comment above.
How do you manage this case
Multidisciplinary team approach Oncologist , dermatologist, Anesthesiologist, transplant surgeon and Physicians
Histological staging of BCC
>3cm on scalp is a high risk.
Management with the goal of achieving a complete resection, the best technique is Mohs micrographic surgery (MMS)
Switching CNI to mTOR inhibitors after 3 months
Preventive measures
Sun avoidance, sun protective clothes and sun blocks.
Regular self-skin examination
Annual review by physician or dermatology.
Reference
Puig S, Berrocal A. Management of high-risk and advanced basal cell carcinoma. Clin Transl Oncol. 2015 Jul;17(7):497-503. doi: 10.1007/s12094-014-1272-9. Epub 2015 Feb 3. PMID: 25643667; PMCID: PMC4495248.
Sirolimus Therapy after Early Cyclosporine Withdrawal Reduces the Risk for Cancer in Adult Renal Transplantation
Will you proceed with the transplantation as planned?
Yes, I would proceed for renal transplant.
Diagnosis and staging are already available.
Long waiting time of recipient
Zero waiting time for BCC
Can proceed in single settings.
👉 Basal cell carcinoma is locally malignant tumor with no metastatasis, so no waiting time after it’s excision.
👉 Treatment of BCC is either by surgery, Mohs surgery, curettage. So we can do it and proceed directly to tranplantation.
👉 The patient has been on waiting list for 6 years , and is so difficult to get another kidney offer, so I will proceed.
👉 No need for induction therapy, he is old and Negative cross match and no DSA.
👉 As regard maintenance therapy, use of tripple therapy as 212 mismatch, but avoidance of MMF and azathioprine is advised and use of mTORi can decrease risk of skin cancer.
⭐ Counseling regarding avoidance of sun exposure around midday, use of sunscreen SP 50% and broad spectrum against UVA and UVB.
Wearing hats and light colored clothes is advised.
Management depend on the assessment of risk of recurrence ,features of high risk tumors it is MDT include( dermatologist ,plastic surgeon ,oncologist and nephrologist because of transplantation plan
The following characteristics have been proposed as factors associated with increased risk for tumor recurrence :
●Location and size:
•Greater than or equal to 6 mm in diameter in high-risk areas (eg, central face, nose, lips, eyelids, eyebrows, periorbital skin, chin, mandible, ears, preauricular and postauricular areas, temples, hands, feet)
•Over 10 mm in diameter in other areas of the head and neck
•Over 20 mm in diameter in all other areas (excluding hands and feet)
●Aggressive pathologic features
•Morpheaform, sclerosing, or mixed infiltrative .
•Micronodular
•Basosquamous (keratinizing)
●Recurrent lesions
●Lesions in sites of prior radiation therapy (RT)
●Lesions with poorly defined borders
The risk of metastasis for BCC is estimated to be between 0.05 to 0.1 percent. This patient is waiting for 6 years to have kidney transplant .In this special situation i will proceed to kidney transplantation simultaneously with surgical treatment of BCC without waiting time for both .
-Counseling the patient about high risk of recurrence,and the use of protective measures like sunscreen .
– Avoid azathioprine and preferred mTOR instead of CNI
Sorry there is error in reference :
1 .Bichakjian C, et al. Guidelines of care for the management of basal cell carcinoma. Journal of the American Academy of Dermatology. 2019. doi:10.1016/j.jaad.2017.10.006
2. The impact of switching to mTOR inhibitor-based immunosuppression on long-term non-melanoma skin cancer incidence and renal function in kidney and liver transplant recipients. Ren Fail. 2020 Nov;42(1):607-612. doi: 10.1080/0886022X.2020.1785499.
D. Go ahead with the transplant and excision of the BCC simultaneously
Basal cell carcinoma (BCC) is a non-melanocytic skin cancer (i.e. an epithelial tumor) that arises from the basal cells (i.e. the small round cells in the lower layer of the epidermis).
The prognosis for patients with BCC is excellent, but serious morbidity can occur if the disease is allowed to progress.
Surgical Modalities used include electrodesiccation and curettage, excisional surgery, Mohs micrographically controlled surgery, and cryosurgery
Close follow up and monitor the patient
References :
1-MedScape
2-Hand book of kidney Transplant donovitch
A 57-year-old CKD 5 called for cadaveric renal transplantation. He has been on the waiting list for 6 years. 212 mismatch, no DSA and negative FAXM. He was recently diagnosed with biopsy-proven BCC on the scalp waiting for excision (confirmed 2 days before this admission).
How do you manage this case?
A case of BCC candidates for kidney transplantation:
It looks like small lesion which can be treated easily and BCC is considered local malignancy (in site), locally growing without metastasis and there are many lines of treatment such as :
1-Excison (can be done by local anesthetic).
2-Curettage and electrodessication.(for treatment for superficial lesion).
3-Mohs surgery (Mohs often results in better outcomes than some other forms of surgery and other treatments. But it’s also usually more complex and time-consuming ).
4-Prevention by education, awareness and observation. ( about risk or recurrence).
5-Annual self-examination and examination by a physician.
6-Patients should be instructed to avoid excessive sun exposure and to use sunblock.
7-Dermatologic surveillance on a regular basis.
8-De novo sirolimus based protocol should be priority.
Will you proceed with the transplantation as planned?
Yes, I will proceed for transplantation
We recommend no waiting time for candidates with curatively treated (surgically or otherwise) non-metastatic basal cell and squamous cell carcinoma of the skin(2).
We can remove it in the same set as it is simple procedure which can be done by local anesthetic.
References:
1-Handbook of Kidney Transplantation, Gabriel M. Danovitch, MD.
2-Al-Adra DP, Hammel L, Roberts J, et al. Preexisting melanoma and hematological malignancies, prognosis, and timing to solid organ transplantation: A consensus expert opinion statement. Am J Transplant. 2021;21(2):475-483. doi:10.1111/ajt.16324.
3-KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation.
1-How do you manage this case?
This patient had scalp skin lesion (most probably BCC);
-Basal cell carcinoma is slowly growing and rarely spreads to other parts of the body with good prognosis.
-Organ transplant recipients with a history of skin cancer should be followed closely for the development of new lesions, locally recurrent lesions, and metastatic disease.
To confirm diagnosis;
-Excision and biopsy is needed; skin biopsy is needed to confirm diagnosis, subtype and stages of BCC ,usually a shave biopsy can be suitable.
Management;
Preventive measures: (prevention is better than cure);
-Patient Behavioural educational programmes on the benefits of UV protection, periodic self-skin examinations.
-Regular screening and follow up is crucial because recurrence rate is high and there is a risk of developing NMSC or melanoma.
-The patient should be advised to do self-skin examination monthly and total skin examination by dermatologist / 6-12 months.
Treatment;
-Local therapy with chemotherapeutic and immune-modulating agents can be used in small superficial lesions.
-Topical 5% imiquimod or 5 Fluorouracil can be applied for superficial lesions
-Photodynamic Therapy used in treatment and prevention of BCC.
-Surgery; is the main therapy and the approach varies according to tumor size, depth, and location.
-High-risk cases need excision with postoperative margin assessment or a Mohs resection.
2-Will you proceed with the transplantation as planned?
-As this lesion is mostly non-fatal and rarely metastasized and there is graft kidney with a prolonged time of recipient being on the waiting list, so we can proceed with transplantation immediately with close monitoring for recurrence of BCC after transplantation.
Post-transplant management:
-The patient must be informed that, pre-transplant skin cancer is a high risk factor for post-transplant other skin cancers.
-Periodic self examination and examination by a physician are warranted for skin cancer screen in the post-transplant period.
-Patients should be instructed to avoid sun exposure and to use sun blocks
Regarding Immunosuppression:
-Decrease overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential as MTORs.
-Tacrolimus can be switched to m TOR due to it’s anticarcinogenic effect with following of the renal function.
Reference:
1-Dennis P Kim, Kylee J B Kus, Emily Ruiz. Basal Cell Carcinoma Review.Hematology/oncology Clinics of North America 2019 February
2-National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Basal Cell Skin Cancer. NCCN. Version 1.2022 — November 17, 2021; Accessed: February 14, 2022.
How do you manage this case?
Evaluation of solid organ transplant candidates who have a history of skin cancer:
o Complete history and physical examination, sites of skin cancers and palpating the regional nodal basin for high-risk skin cancers
o Review clinical and pathologic details skin cancers. Transplant dermatologists may be helpful
o Estimate the risk of recurrence, metastasis and development of new primary cancers
BCC:
o The risk of death from BCC is vanishingly small. Therefore, in almost all cases, a history of BCC would not be a contraindication to transplantation when considering survival
o Although rare, metastatic BCC is very difficult to treat, and thus it would represent an absolute contraindication to transplantation unless a disease-free interval of at least 5 years had passed since the last manifestation
o The prognosis is almost always favorable for BCC
Options of treatment:
Cryotherapy, curettage, topical therapy 5-FU, imquimod 5%, surgical excision (low risk BCC), and Mohs surgery or micrographic surgery (for high risk)
Will you proceed with the transplantation as planned?
KDIGO guidelines:
Recommend no waiting time for candidates with:
1. Curatively treated (surgically or otherwise) non-metastatic basal cell and squamous cell carcinoma of the skin
2. Melanoma in situ
3. Small renal cell carcinoma (< 3 cm)
4. Prostate cancer (Gleason score ≤ 6)
5. Carcinoma in situ (ductal carcinoma in situ, cervical, others)
6. Thyroid cancer (follicular/papillary < 2 cm of low grade histology)
7. Superficial bladder cancer (1C)
If confirmed to be low risk, the risk of death from BCC is very small and the prognosis is almost always favorable for BCC. Transplant can proceed
Use of mTORi to reduce the risk of recurrence
Patient education:
Patient should be counseled that the risk of skin cancer is high post transplant, especially with the pre-transplant one
Frequent self examination and regular follow-up
Sun protection: patients should be counseled on the use of sunscreens, sun protective clothing, and the warning signs of cutaneous malignancy
References
1. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
2. Clark C. Otleya, Ryutaro Hiroseb, Stuart J. Salaschec. Skin Cancer as a Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5: 2079–2084
Dear colleagues,
Apologies for my comment , it is not a ‘Russian Roulette’ game that the fate (probability) will decide the outcome or approach.
Please go through my response (or other faculty members’ reply) that woudl be of help in planning the treatment and timing. Please justify your reply from the following 4 options, 5th one is mentioned by Prof Halawa for anyone who is permanently confused.
-I f the case is Low-Risk BCCs treatment includes Cryotherapy , curettage with electrodesiccation; Surgical excision, topical imiquimod ,intralesional interferon and photodynamic therapy
For High-Risk BCCs Mohs micrographic surgery and definitive radiation therapy .
Transplant-associated immunosuppression may be tailored to minimize the risk of recurrent or denovo BCC because cancer development correlates with the duration and intensity of immunosuppression.
Immunosuppressives dose reduction can be stratified into mild, moderate, and severe by risk of permanent allograft function and death.
Mammalian target of rapamycin (mTOR) inhibitors can be used as it may be associated with a decreased incidence of skin cancer compared to CNI usage.
This recipients should be followed closely for the development of new lesions, locally recurrent lesions, and metastatic disease
Secondary prophylaxis will be needed sun protection and education about self skin examination and screening is essential too.
-The basal cell carcinoma can be surgically excised at least a 4-mm margin,the cure rate is approximately 90% in the recipients as a locally malignant tumor and the renal transplant operation can be proceeded afterwards.
The risk of death from BCC is extremely low , in almost all cases, a history of BCC would not be considered a contraindication to transplantation when considering survival.
Reference
-Otley et al. Skin Cancer as a Contraindication to Organ Transplantation .American Journal of Transplantation 2005; 5: 2079–2084
-M.K. Singh and J.D. Brewer. Current Approaches to Skin Cancer Management in Organ Transplant Recipients. Semin Cutan Med Surg 30:35-47;2011 Elsevier
A 57-year-old CKD 5 called for cadaveric renal transplantation. He has been on the waiting list for 6 years. 212 mismatch, no DSA and negative FAXM. He was recently diagnosed with biopsy-proven BCC on the scalp waiting for excision (confirmed 2 days before this admission).
==================================================================
Basal cell carcinoma
==================================================================
How do you manage this case?
Treatment
Treatment for basal cell carcinoma is based on the type, location and size of the cancer, as well as patient preferences and ability to follow-up.
Surgery
Options might include:
Other treatments include
====================================================================
Will you proceed with the transplantation as planned?
===================================================================
Reference
Management of BCC
For transplantation; as this tumor is mostly non-fatal and rarely metastasized and we have a graft kidney with a prolonged time of recipient being on the waiting list, so we can proceed with transplantation immediately with close monitoring for recurrence of BCC after transplantation.
references
I like your approach.
·How do you manage this case?
Treatment
The goal of treatment:
Treatment modalities:
Surgical methods:
Surgical techniques:
Nonsurgical methods:
==========================
·Will you proceed with the transplantation as planned?
References
Surgery is mistyped as Suregery.
What does radical excision, as you suggested, mean? Would it be needed for BCC? Do you mean complete excision?
THANK YOY, DEAR PROF. AJAY
Complete excision to prevent local invasion to deeper tissues.
YOU
Investigations – Major investigation is skin biopsy and histology. Other investigations like x-ray, CT scan may be needed only when the is likelihood of tumor infiltration. However, its usually not needed as tumor rarely metastasize.
Treatment – The treatment for a BCC depends on its type, size and location, the number to be treated, patient factors, and the preference or expertise of the doctor. Most BCCs are treated surgically. Long-term follow-up is recommended to check for new lesions and recurrence; the latter may be unnecessary if histology has reported wide clear margins.
Modes of treatment
Excision biopsy – lesion is excised and the skin stitched up.
Mohs micrographically controlled excision – Mohs micrographically controlled surgery involves examining carefully marked excised tissue under the microscope, layer by layer, to ensure complete excision. It has very high cure rates achieved by trained Mohs surgeons. Suitable for ill-defined, morphoeic, infiltrative and recurrent subtypes.
Superficial skin surgery – Superficial skin surgery comprises shave, curettage, and electrocautery. It is a rapid technique using local anaesthesia and does not require sutures. Suitable for small, well-defined nodular or superficial BCCs.
Cryotherapy – Cryotherapy is the treatment of a superficial skin lesion by freezing it, usually with liquid nitrogen. Suitable for small superficial BCCs on covered areas of trunk and limbs.
Photodynamic therapy – Photodynamic therapy (PDT) refers to a technique in which BCC is treated with a photosensitising chemical and exposed to light several hours later. Topical photosensitisers include aminolevulinic acid lotion and methyl aminolevulinate cream. Suitable for low-risk small, superficial BCCs.
Imiquimod cream – Imiquimod is an immune response modifier. Best used for superficial BCCs less than 2 cm diameter.
Fluorouracil cream – 5-Fluorouracil cream is a topical cytotoxic agent.Used to treat small superficial basal cell carcinomas. Requires prolonged course, eg twice daily for 6–12 weeks.
Radiotherapy – Radiotherapy or X-ray treatment can be used to treat primary BCCs or as adjunctive treatment if margins are incomplete. Mainly used if surgery is not suitable.
I will proceed with the transplantation as planned. The treatment will be offered after the transplantation.
References
Thankyou What is the wait time after excision of BCC?
No wait time because the tumor is locally invasive and rarely metasize.
How will you manage this case?
The following questions will guide the management of the case
Basal cell carcinoma is benign cancer that rarely metastases and it requires no waiting time to proceed with the surgery
Investigations will be done to rule out metastasis or any other active malignancy
Things to note before and after the transplant
Yes I will proceed with the transplantation on account of :
References
To avoid the prolonged cold ischemic time, kidney transplantation will be done first, and the excision of the BCC will be carried out when the patient is stable after the surgery
If you are removing this locally malignant tumor with no wait time and performing the TX
would it be in the same sitting or consecutive?
What would be your management for the exision site.
Risk of recurrence and death from pre-transplantationbasal cell carcinoma
The possibility of dying from BCC is incredibly unlikely.
A history of BCC would therefore almost never be a contraindication to transplantation when assessing survival.
Although though it is uncommon, metastatic BCC is extremely difficult to treat, making it a strict no-no for transplantation unless at least five years have passed since the last symptomatologic manifestation of the illness.
Risk of multiple de novo nonmelanoma skin cancerspost-transplantation
Although nonmelanoma skin cancer (NMSC)-related deaths are infrequent, pre-transplant BCC or SCC are indicators of a higher risk of developing multiple de novo NMSCs after transplantation.
Even in non-immunosuppressed patients, 44% of those with past BCC develop another BCC within 3 years, and 6% develop an SCC within 3 years.
Before the patient is given the option of receiving an organ transplant, NMSCs should be treated as an opportunity to begin strong preventive measures, including sun protection, under the direct supervision of a competent dermatologist.
Skin Cancer as a Contraindicationto Organ TransplantationClark C. Otleya,∗,Ryutaro Hiroseband Stuart J. Salasche
Thankyou but you seem to consider BCC and SCC equally, can you revise the wait time for each.!
Usual Wait Time of 2 Years
• Most cancers
No Wait Time Necessary
• Incidental renal carcinoma
• In situ carcinoma
• Focal neoplasm (defined as a localized tumor without metastases)
• Low-grade bladder cancer
• Basal cell skin cancer
Wait Time of More Than 2 Years May Be Necessary
• Melanoma
• Breast cancer
• Colorectal cancer
• Uterine cance
Basal cell carcinoma diagnosed prior to transplantation is not a contraindication to proceed with transplantation after treatment of the primary focus and excluding local and distant metastasis . However, a patient with skin basal cell carcinoma is at higher risk of developing recurrent tumors after transplantation, and intensive regular follow up is indicated with precautionary avoidance of sun exposure.
Reference:
1]B Imko-Walczuk et al . Skin Cancers as Contraindication to Organ Transplantation. Transplant Proc. 2015 Jul-Aug;47(6)
So are you declining this kidney?
Thanks, All
This patient is sitting in front of you with a
kidney in a box. What would you advise the surgeon to do?
A. Cancel the transplant and remove the patient from the waiting list.
B. Proceed with the transplant and excise the BCC later, as it is locally malignant.
C. Cancel the transplant and ask the surgeon to remove the BCC first
D. Go ahead with the transplant and excision of the BCC simultaneously.
E. None of the above
Please justify your selection
B
Please justify your answer
C
Please justify your answer
A. false, the kidney is wasted, since we have it now why can we proceed !
B. correct( better answer), the patient is in need for this kidney, no waiting time for BCC but he may be at risk of recurrence. This should come out clearly
C. false, by that time the kidney may not be suitable for transplantation e.g. cold ischemia time may be prolonged and no reason to do this.
D. false, transplant is a long procedures and may get complicated, so it inappropriate to multi task
E. false, something need to be done for this pt.
If the transplant is a long procedure, do you think excision of this lesion will prolong the procedure on the expense of leaving this lesion with immunosuppression?
Thnxs prof Mohsen:
Here are my personal views on this matter and it may not be necessarily correct
Thank you for justifying your answer. I agree this is not straightforward case and not that frequent and there is no correct or wrong here. It’s how you think in the case of challenging situation.
Most welcome, prof. We are happy to see your guidance here.
C
Please justify your answer
B
Please justify your answer
Basal cell carcinoma generally has a good prognosis and rarely metastasize, hence it can be easily excised later.
D
Please justify your answer
Counsel the patient with pros and cons and higher incidence of recurrent post trasnplant. If the patient understand the risk and importance of skin protection, creams will discuss with transplant surgeon. To proceed with Transplant
Close follow up and consider use mtor later as part of his immunosupression.
So which option you would prefer?
B
I will go a head with transplantation
Laiase with dermatology to excise it immediatly post op (I don’t think Tx surgeon are trained to excise it)
Consider Sirolimus after complete wound healing, as Sirolimus associated with poor wound healing
Ideally any skin cancer should be managed before transplantation, but because the patient is on the waiting list for 6 months, and should be transplanted soon, I will choose to do transplantation and then do the excision later on under strict aseptic technique and after reduction of steroid dose to allow for healing,
No need to excise BCC at the same setting with transplant surgery as it is slowly growing locally invasive (no problem if we wait) and we will use induction therapy including pulse steroid therapy which will affect healing later on
So … I will choose B
Ideally any skin cancer should be managed before transplantation, but because the patient is on the waiting list for 6 months, and should be transplanted soon, I will choose to do transplantation and then do the excision later on under strict aseptic technique
No need to excise BCC at the same setting with transplant surgery as it is slowly growing locally invasive (no problem if we wait)
So … I will choose B
The answer is D
Many thanks Prof Halawa
D. Go ahead with the transplant and excision of the BCC simultaneously.
Well done, see my reply above.
Answer;B
multidisciplinary, team-based approach involving a dermatologist and transplant team along with patient counselling
The risk factors, individual patient characteristics, and tumor burden need to be considered
in the current case proceeding with the transplantation then dealing with BCC can be done by variable modalities as cryotherapy, or curettage with electrodesiccation; if it is considered a low risk which is small in size ,less than 2 cm in diameter with well defined borders and in histology is superficial or nodular subtype
Reference
M.K. Singh and J.D. Brewer. Current Approaches to Skin Cancer Management in Organ Transplant Recipients. Semin Cutan Med Surg 30:35-47;2011 Elsevier
See my reply above.
The risk of death from BCC is very small and in almost all cases, a history of BCC would not be a contraindication to transplantation when considering survival. Prognosis is almost always favorable for BCC. In spite of all these, BBC should be treated before transplantation. Actually any malignancy should be treated before transplantation
KDIGO guidelines: Recommend no waiting time for candidates with curatively treated (surgically or otherwise) non-metastatic basal cell and squamous cell carcinoma of the skin
Reference
1. Clark C. Otleya, Ryutaro Hiroseb, Stuart J. Salaschec. Skin Cancer as a Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5: 2079–2084
2. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020
B..As BCC is locally malignant and rarely metastasize.
If our transplant surgeon has agood experience with removal of skin tumour with wide margin, this could be an option.
However to chose one, best answer, i will go with B.
See my reply above.
B-
As this lesion is mostly non-fatal and rarely metastasized and there is graft kidney with a prolonged time of recipient being on the waiting list, so we can proceed with transplantation immediately with close monitoring for recurrence of BCC after transplantation.
Post-transplant management:
Treatment;
-Local therapy with chemotherapeutic and immune-modulating agents can be used in small superficial lesions (after Dermatology referral)
-Topical 5% imiquimod or 5 Fluorouracil can be applied for superficial lesions.
-The patient must be informed that, pre-transplant skin cancer is a high risk factor for post-transplant other skin cancers.
-Periodic self examination and examination by a physician are warranted for skin cancer screen in the post-transplant period.
-Patients should be instructed to avoid sun exposure and to use sun blocks
Regarding Immunosuppression:
-Decrease overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential as MTORs.
-Tacrolimus can be switched to m TOR due to it’s anticarcinogenic effect with following of the renal function.
See my reply above.
D
this answer is justified by trying to avoid putting patient on waiting list again and avoid dialysis related morbidity and mortality
and also justified by the rarity of BCC metastasis
so, will proceed to do both procedure in the same time
Well done, see my reply above.
My answer is D.
As It is BCC which is locally malignant and no waiting time needed after its removal.
And Its removal is simple and not need more time and could be done at time of transplantation.
References:
1-Canadian Society of Transplantation: consensus guidelines on eligibility for kidney transplantationGreg Knoll, Sandra Cockfield, Tom Blydt-Hansen, Dana Baran, Bryce Kiberd, David Landsberg, David Rush, Edward Cole and ; for The Kidney Transplant Working Group of the Canadian Society of Transplantation
CMAJ November 08, 2005 173 (10) S1-S25; DOI: https://doi.org/10.1503/cmaj.1041588.
2-KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation.
Well done, see my reply above.
My answer is D :
The risk of metastasis for BCC is estimated to be between 0.05 to 0.1 percent. This patient is waiting for 6 years to have kidney transplant .In this special situation I will proceed to kidney transplantation simultaneously with surgical treatment of BCC without waiting time for both
Well done, see my reply above.
I will choose D.
👉 BCc is locally malignant tumor with no metastasis and no waiting time after its ttt.
⭐ it is not wise to cancel in such patient on waiting list for 6 years and so difficult to get another offer easily
👉 Even its surgical removal is a simple procedure, will not prolong or be problematic together with transplant procedure (in the same anasthesia setting) .
⭐ I think it is better to do it now, as the prolonged use of mTORi thereafter will impair the wound healing.
Well done, see my reply above.
Ans: D
Diagnosis and staging are already available.
Zero waiting time for BCC
Long waiting time of recipient -6 yrs
Can proceed in single settings.
Cost effective.
No waste of time for revisit, don’t know when the next OT time will be.
Though rare, metastatic risk are higher with immunosuppression.
Clark C. Otley, Wida S. Cherikh, Stuart J. Salasche, Maureen A. McBride, Leslie J. Christenson, H. Myron Kauffman,Skin cancer in organ transplant recipients: Effect of pretransplant end-organ disease,Journal of the American Academy of Dermatology,Volume 53, Issue 5,2005,Pages 783-790,ISSN 0190-9622,https://doi.org/10.1016/j.jaad.2005.07.061.
Well done, see my reply above.
This lesion seems to be of low risk BCC : well-defined and small (<2cm)
I would to go with option D: Go ahead with the transplant and excision of the BCC simultaneously
Singh MK, Brewer JD. Current approaches to skin cancer management in organ transplant recipients. InSeminars in Cutaneous Medicine and Surgery 2011 Mar 31 (Vol. 30, No. 1, pp. 35-47). WB Saunders.
Well done, see my reply above.
I would advise the surgeon to go ahead with the transplant and excision of BCC simultaneously (option D).
This appears to be a low-risk (easy-to-treat) BCC in view of (1)
Surgical excision in this case is (1)
Safety margin(1)
Also, various guidelines do advocate no waitlist time in cases of localized non-melanoma skin cancers in view of (2)
Follow-up post-transplant:
References:
Well done, see my reply above.
C
BCC has no waiting list in case of localized disease but transplantation before excising the tumor and the patient will be immunocompromized is unwise
the two operation practical it will be technically difficult as transplant operation is a long procedure
See my reply above.
This patient is sitting in front of you with a kidney in a box. What would you advise the surgeon to do?
A. Cancel the transplant and remove the patient from the waiting list= False as he had been on waiting list for long time (6 years), and it is will known being long time on waiting list associated with more mortality, and comorbidity.
B. Proceed with the transplant and excise the BCC later, as it is locally malignant = False, because the tumor may progress and transform to other high risk category.
C. Cancel the transplant and ask the surgeon to remove the BCC first- False, the patient has been for long time on waiting list and this option would not be easy to have.
D. Go ahead with the transplant and excision of the BCC simultaneously.= True, it is in a low risk area small, easly resectable with low recurrence rate, however, patient education for prevention and frequenmonitoring is a must.
E. None of the above-= False
Answer is D
Reference:
Kim DP, Kus KJB, Ruiz E. Basal Cell Carcinoma Review. Hematol Oncol Clin North Am. 2019 Feb;33(1):13-24. doi: 10.1016/j.hoc.2018.09.004. PMID: 30497670.
He is waiting list for 6 years. 212 mismatch, no DSA and negative FAXM. He was recently diagnosed with biopsy-proven BCC on the scalp waiting for excision (confirmed 2 days before this admission)===> B ===> is the correct, tas no waiting time for BCC but he may be at risk of recurrence.
(B)AS this BCC is mostly non-fatal and rarely metastasized, so we can proceed with transplantation with close monitoring for recurrence of BCC after transplantation.
See my reply above.
See my reply above.
B. Proceed with the transplant and excise the BCC later, as it is locally malignant.
For basal cell carcinoma, the cure rate is around 99%. Mohs micrographic surgery (MMS) provides the best long-term cure rate of any treatment modality for BCC. MMS is the gold standard for treating high-risk BCCs and recurrent BCCs because of its high cure rate and tissue-sparing benefit. The high cure rate is attributed to an examination of 100% of all the tissue margins and no delay necessary(1).
Reference
1. Zwald F, Leitenberger J, Zeitouni N, Soon S, Brewer J, Arron S, Bordeaux J, Chung C, Abdelmalek M, Billingsley E, Vidimos A, Stasko T. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016 Feb;16(2):407-13. doi: 10.1111/ajt.13593. Epub 2016 Jan 28. PMID: 26820755.
See my reply above.
answer: D
I will go ahead with the transplant and remove the BCC simultaneously. provided that, there are no Mets (rarely). It is important for the patient to be aware of the fact that having pretransplant skin cancer is in and of itself a risk factor for developing posttransplant skin cancer.
Well done, see my reply above.
This is a patient on the waiting list for six years and has gotten a 5/6 mismatch kidney with no DSAs
Keeping in mind that it has taken six years to get an opportunity at transplant and he a basal cell carcinoma, I would proceed with the transplant and excision of the lesion simultaneously, Once healing of both wounds has finished, I would switch to an mTOR inhibitor
Well done, see my reply above.
Yes, D is the correct answer
Thank you Professor Halawa
A. False, this is a localized skin tumor less invasive and still can go for transplantation and has already been diagnosed and there is a decision for surgical removal.
B. True, BCC is more frequent than SCC in the general population but after transplantation, the SCC behaves more aggressively so based on the nature of the BCC we still can go for transplantation and consider surgical excision after transplantation with modification of maintenance IS with early conversion to sirolimus-based and CNI minimization, in addition to the deliver good education for self-skin examination and use of sunblock and avoid sun exposure
C. False, localized skin tumor is not an absolute contraindication for transplantation taking into consideration this patient has been on a prolonged waiting list for> 6 years
D.True we can still go ahead with transplantation and the rationale of this individualized decision based on two points
First the type of cancer and its prognosis, localized BCC is less likely to disseminate compared to multifocal or locally invasive SCC(1).
Second what influence is post-transplant immunosuppression likely to have on tumor course? Non-melanoma skin cancer including SCC followed by BCC with an increased incidence ratio of 16.4, and responsible for> 40% of the skin cancers after transplantation. so we need sharing decisions with the transplant surgeon and the oncologist after discussion with the transplant recipient and can be removed locally in one-stage surgery or second-step surgery upon FU with modification of maintenance IS
The correct answer for both B , D, remembered the evidence is limited and there is always room to justify your decision after MDT discussion and justification .
references
kidney transplantation hand book 6th edition.
Well done, see my reply above.
Yes, D is the correct answer
D
BCC is not very aggressive and rarely metastasize. Recient has been on waiting list for long time. Graft should be saved and BCC can be excised later. However patient education and couselling before surgery is maadtory.
Well done, see my reply above.
Yes, D is the correct answer
Option D: Simultaneous transplantation and surgical BCC excision seems reasonable for the following:
-Candidate is old age patient with long waiting time on transplant list.
-Tumor has low risk for metastasis.
– Prognosis generally good.
– Reduce cold ischemia time.
Well done, see my reply above.
Yes, D is the correct answer
D is the best answer in my point of view.
intra-operative excision of the scalp lesion will take few minutes.
There is no point of cancelling the operation for Locally malignant tumor which easily treated with surgical excision. ( A option_
it is not point to excise the BCC later and expose the patient to heart IS with malignant tumor to be excised later in another procedure. (B-option).
Cancelling the operation means losing the renal transplant offer and continue to wait on the transplant list for longer.
Well done, see my reply above.
Yes, D is the correct answer
I prefer to go for surgical excision with clear margin with closure of surgical defect.
Option D: Simultaneous transplantation and surgical BCC excision seem reasonable for the following:
-Candidate is old age patient with long waiting time on transplant list.
-Tumor has low risk for metastasis.
– Prognosis generally good.
– Reduce cold ischemia time.
Well done, see my reply above.
Yes, D is the correct answer
D. This patient has been on a wait-list for long time, the kidney has already been offered, and the diagnosis is a BCC (which is a slowly growing tumor). Both the procedures can be done simultaneously, if logistics are not an issue.
If simultaneous procedure is not possible, then situation B would be my second choice.
Canceling the transplant in this scenario is not an option at all.
Well done, see my reply above.
Yes, D is the correct answer
Well done, see my reply above.
Yes, D is the correct answer
D. Go ahead with the transplant and excision of the BCC simultaneously, is the correct answer. I have excised the lesion simultaneously with the transplantation.. The tumour was very close to the margin, which was re-excised.
A. Tx is better than other modalities and BBC is rarely metastases.
B. Possible but why not simultaneously
C. Not agree by wasting organ/increasing cold ischemia.
D. Agree
D
This patient has BCC and has been called for transplant.
Canceling the transplant will lead to wastage of the organ and postponing the transplant will prolong the cold ischaemic time
Leaving it and proceeding with transplant will lead to recurrence due to the immunosuppressive regimens.
Since this type rarely metastasises I would recommended transplantation and excision at the same time.
KDIGO 2020 CLICAL PRACTICE GUIDELINES FOR EVALUATION AND MANAGEMENT OF CANDIDATES FOR KIDNEY TRANSPLANATATION
I will go ahead with option D.
B.
The risk of death from BCC is small.
Therefore, in almost all cases, a history of BCC would not be a contraindication to transplantation when considering survival.
Refences:
Clark C. Otleya,Ryutaro Hiroseb and Stuart J. Salasche.Skin Cancer as a
Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5:
2079–2084.
D
The answer for me is D
He is on waiting list for six years, and to get a chance of another donor is near future seems impossible.
would prefer Sirolimus as part of immunosupression protocol
I would go with option D and go ahead with the transplant and excise the BCC at the same time. This is because there is no waiting time for BCC as it is locally invasive and does not metastasise. It is important to ensure clear margins. Patient will need to be counselled on preventive measures for skin cancer as there is a high chance of recurrence after transplantation. I would give standard induction with Methylpred and Basiliximab followed by CNI based regimen. I would consider switching to M-TORi after wound healing as it is associated with reduces incidence of cancer.
I am in favor of option D. I want to proceed to this transplantation with simultaneous Mohs micrographic surgery (MMS) of this BCC and renal transplantation. Here, multidisciplinary approach is needed including plastic surgeon, transplant surgeon, nephrologist, dermatologist and oncologist. Appropriate counseling is paramount here along with close post-transplant follow-up with emphasis on sun-protective behavior.
An mTOR inhibitor based immunosuppressive regimen would be preferable in this scenario.
B
Because BCC is a non-aggressive ,non metastatic skin cancer and mostly cure with surgical excision
Answer D: perform the kidney transplant and excision of the BCC simultaneously (1, 2)
– BCC is usually a locally destructive tumor hence the prognosis is almost always favourable for BCC compared with SCC
– in very rare circumstances BCC may be locally advanced or metastasize
– BCC is not a contraindication to transplantation unless it is metastatic BCC
– metastatic BCC is rare, difficult to treat hence requires a 5year disease-free interval before transplantation can be considered
References
1. Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2005 Sep;5(9):2079-84. PubMed PMID: 16095486. Epub 2005/08/13. eng.
2. Mittal A, Colegio OR. Skin Cancers in Organ Transplant Recipients. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2017 Oct;17(10):2509-30. PubMed PMID: 28556451. Epub 2017/05/31. eng.
Cancelling the transplant will waste the kidneys and increase the cold ischemia time till another potential donor is identified.
Either leaving it till later (suppose it occurred later) or remove simultaneously by another surgon in the team could be wise. Since BCC is localised ca
B/D
B – Proceed with transplantation, BCC are hardly invasive and malignant, we proceed with the transplant and opt remove it electively post op after doing the necessary workup.The pt has to be counseled on the risk of recurrence and the appropriate measures to take to prevent or reduce risk factors for getting skin malignancies. The transplant team should consider use of MTORi in comparison to CNIs to reduce risk of skin lesions post op.
D
· This lesion looks superficial. Curettage can be done and re-evaluate.
· No waiting time is needed for curatively treated non-metastatic basal cell and squamous cell carcinoma of the skin.
· BCCs have a much more limited biologic potential for metastasis and death, with treatment emphasis instead focused on limiting morbidity from disease.
1)KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation
2) Skin Cancer in Solid Organ Transplant Recipients: A Review for the Non-dermatologist.
The answer D Go ahead with the transplant and excision of the BCC simultaneously
●The patient has been on the waiting list for 6 years●no DSA
●Basal cell carcinoma (BCC) accounts for 80% of nonmelanoma skin cancers. However, metastasis is extremely rare, ranging between 0.0028 and 0.55 of BCC cases, with prognosis remaining poor.
REFERENCES
Metastatic Basal Cell Carcinoma: A Biological Continuum of Basal Cell Carcinoma?Karaninder S. Mehta06 Dec 2012
Metastatic and locally aggressive BCC: Current treatment optionsMáire-Caitlín Casey, 15 October 2021
D. This patient has been on a wait-list for long time, the kidney has already been offered, and the diagnosis is a BCC (which is a slowly growing tumor). Both the procedures can be done simultaneously, if logistics are not an issue.
If simultaneous procedure is not possible, then situation B would be my second choice.
Cancelling the transplant in this scenario is not an option at all.
D is correct because the patient was on the waiting list for a long time an BCC is usually completely cured with excisional biopsy and there is no need for waiting time to TX
Q1.
Management is MTD including transplant dermatologist, surgeon, & counselors
Q2.
Posttransplant management: Education, awarenes ,& observation
Immune-suppression:
source, Hand book of kidney transplantation 6 th edition, ITSCC, http://www.itscc.org
Exellent.
How do you manage this case? Will you proceed with the transplantation as planned?
REFERANCES
1. Park CK, Fung K, Austin PC, et al. Incidence and Risk Factors of Keratinocyte Carcinoma After First Solid Organ Transplant in Ontario, Canada. JAMA Dermatol 2019; 155:1041.
2. Chockalingam R, Downing C, Tyring SK. Cutaneous Squamous Cell Carcinomas in Organ Transplant Recipients. J Clin Med 2015; 4:1229.
3. Kuschal C, Thoms KM, Boeckmann L, et al. Cyclosporin A inhibits nucleotide excision repair via downregulation of the xeroderma pigmentosum group A and G proteins, which is mediated by calcineurin inhibition. Exp Dermatol 2011; 20:795.
Well done is there another option for his maintenance IS.
How do you manage this case?
Imiquimod is a topical immunostimulatory agent that is sometimes used for the treatment of superficial BCC. The use of imiquimod for limited periods on small areas (60 to 100 cm2) appears to be safe in organ transplant recipients
Topical fluorouracil 5% cream or solution is an approved topical treatment for superficial BCC.
Photodynamic therapy (PDT) is a noninvasive, nonscarring treatment option for superficial BCCs . PDT consists of topical application of a photosensitizer (methyl aminolevulinate [MAL] or 5-aminolevulinic acid [ALA]) followed, after a variable incubation time, by irradiation with a red or blue light
Will you proceed with the transplantation as planned?
Yes I Will proceed with the transplantation as planned
For patients with basal cell carcinoma or low-risk squamous cell carcinoma (SCC) that has been surgically excised with clear margins, no waiting time is required.
Well done.
Will you need induction in this case?
Any suggestions for maintenance IS
Perform a physical examination, paying specific attention to sites of prior skin cancer and palpating the regional LNs.
Yes, if it is primary, localized, and excised with a safety margin. after consulting the dermatologist and oncologist and counseling the patient on the risk of recurrence post-transplantation.
Otley, C. C., Hirose, R., & Salasche, S. J. (2005). Skin cancer as a contraindication to organ transplantation. American journal of transplantation, 5(9), 2079-2084.
Can you revise the wait time for BCC .!
5 years for BCC with the Mets.
There is no waiting time for localized time.
How do you manage this case?
Excision of the lesion with free margins and proceed with imaging tests to assess whether there were metastases.
Use sunscreen, clothing with UV protection, avoid certain times of higher concentration of sunlight, self-examination, and physical examination with the transplant team in search of new lesions.
Will you proceed with the transplantation as planned?
If there is no metastasis and the excision is removed with free margins, I would proceed with the transplant and not use calcineurin inhibitors, prioritizing mTor inhibitors.
Thanks, Filipe
BCC is a locally malignant tumour of the skin. It does not metastasis. Please review your answer.
Sorry, Professor. That is true.
If the patient has an excision with free-margin tumors I will proceed with transplantation.
Thanks, Filipe
The risk of death from BCC is small.
in almost all cases, a history of BCC would not be a contraindication to transplantation when considering survival.
Although rare, metastatic BCC is very difficult to treat, and thus it would represent an absolute contraindication to transplantation unless a disease-free interval of at least 5 years had passed since the last manifestation.
management is excisional biopsy
and check for metastasis
so, will not proceed for planned transplantation until excised with free margin and confirmed no metastasis
after excision with free margin and confirmed no metastasis, we can proceed for transplantation
Clark C. Otleya, Ryutaro Hiroseb and Stuart J. Salaschec. Skin Cancer as a Contraindication to Organ Transplantation. American Journal of Transplantation 2005; 5: 2079–2084
Thanks, Riham
Therefore, you will cancel the transplant. He may die while waiting for another offer.
Please review your answer.
ok, will proceed for transplantation with the excision of BCC in the same sitting
B
How do you manage this case?
Dermatology referral to search for metastasis.
Will you proceed with the transplantation as planned?
The possibility of dying from BCC is incredibly unlikely. Consequently, when evaluating survival, a history of BCC nearly never acts as a barrier to transplantation. Although uncommon, metastatic BCC is extremely difficult to cure, making it an absolute contraindication to transplantation unless at least five years have gone since the last symptomatic manifestation and the patient has been disease-free.
Skin Cancer as a Contraindication to Organ Transplantation
Clark C. Otleya et al